Lack of insurance negatively affects trauma mortality in US children

Purpose

Uninsured children face health-related disparities in screening, treatment, and outcomes. To ensure payer status would not influence the decision to provide emergency care, the Emergency Medical Treatment and Active Labor Act (EMTALA) was passed in 1986, which states patients cannot be refused treatment or transferred from one hospital to another when medically unstable. Given findings indicating the widespread nature of disparities based on insurance, we hypothesized that a disparity in patient outcome (death) after trauma among the uninsured may exist, despite the EMTALA.

Methods

Data on patients age 17 years or younger (n = 174,921) were collected from the National Trauma Data Bank (2002-2006), containing data from more than 900 trauma centers in the United States. We controlled for race, injury severity score, sex, and injury type to detect differences in mortality among the uninsured and insured. Logistic regression with adjustment for clustering on hospital was used.

Results

Crude analysis revealed higher mortality for uninsured children and adolescents compared with the commercially or publicly insured (odds ratio [OR] 2.97; 95% confidence interval [CI], 2.64-3.34; P < .001). Controlling for sex, race, age, injury severity, and injury type, and clustering within hospital facility, uninsured children had the highest mortality compared with the commercially insured (OR, 3.32; 95% CI, 2.95-3.74; P < .001], whereas children and adolescents with Medicaid also had higher mortality (OR, 1.19; 95% CI, 1.07-1.33; P = .001).

Conclusions

These results demonstrate that uninsured and publicly insured American children and adolescents have higher mortality after sustaining trauma while accounting for a priori confounders. Possible mechanisms for this disparity include treatment delay, receipt of fewer diagnostic tests, and decreased health literacy, among others.     

Ureteral trauma: Patterns and mechanisms of injury of an uncommon condition

Background

Traumatic ureteral injuries are uncommon, thus large series are lacking.

Methods

We performed a retrospective analysis of the National Trauma Data Bank (2002-2006).

Results

Of the 22,706 genitourinary injuries, 582 ureteral injury patients were identified (38.5% blunt, 61.5% penetrating). Patients were 84% male, 38% white, and 37% black (mean age, 31 y). Blunt trauma patients had a median Injury Severity Score of 21.5 versus 16.0 for penetrating injury (P < .001). Mortality rates were 9% blunt, and 6% penetrating (P = .166). Penetrating trauma patients had a higher incidence of bowel injuries (small bowel, 46%; large bowel, 44%) and vascular injuries (38%), whereas blunt trauma patients had a higher incidence of bony pelvic injuries (20%) (P < .001).

Conclusions

Ureteral injuries are uncommon, seen in approximately 3 per 10,000 trauma admissions, and occur more in penetrating than in blunt trauma. The most common associated injury for blunt ureteral trauma is pelvic bone fracture, whereas penetrating ureteral trauma patients have more hollow viscus and vascular injuries.     

The Trauma and Injury Severity Score (TRISS) revised

Background

The Trauma and Injury Severity Score (TRISS) remains the most commonly used tool for benchmarking trauma fatality outcome. Recently, it was demonstrated that the predictive power of TRISS could be substantially improved by re-classifying the component variables and treating the variable categories nominally. This study aims to develop revised TRISS models using re-classified variables, to assess these models’ predictive performances against existing TRISS models, and to identify and recommend a preferred TRISS model.

Materials and methods

Revised TRISS models for blunt and penetrating injury mechanism were developed on an adult (aged ≥15 years) sample from the National Trauma Data Bank National Sample Project (NSP), using 5-category variable classifications and weighted logistic regression. Their predictive performances were then assessed against existing TRISS models on the unweighted NSP, National Trauma Data Bank (NTDB), and New Zealand Database (NZDB) samples using area under the Receiver Operating Characteristic curve (AUC) and Bayesian Information Criterion (BIC) statistics.

Results

The weighted NSP sample included 1,124,001 adults with blunt or penetrating injury mechanism events and known discharge status, of whom 1,061,709 (94.5%) survived to discharge. Complete information for all TRISS variables was available for 896,212 (79.7%). Revised TRISS models that included main-effects and two-factor interaction terms had superior AUC and BIC statistics to main-effects models and existing TRISS models for patients with complete data in NSP, NTDB and NZDB samples. Predictive performance decreased as the number of variables with missing values included within revised TRISS models increased, but model performances generally remained superior to existing TRISS models.

Discussion

Revised TRISS models had importantly improved predictive capacities over existing TRISS models. Additionally, they were easily computed, utilised only those variables already collected for existing TRISS models, and could be applied and produce meaningful survival probabilities when one or more of the predictor variables contained missing values. The preferred revised TRISS model included main-effects and two-factor interaction terms and allowed for missing values in all predictor variables. A strong case exists for replacing existing TRISS models in trauma scoring systems benchmarking software with this preferred revised TRISS model.     

The paradoxical effect of medical insurance on delivery of surgical care for infants with congenital anomalies

Objective

Caring for neonates with major congenital anomalies has significant financial implications for the treating institution, which can be positive or negative depending on whether the patient has insurance. We hypothesized that insured affected neonates born in non-children's hospitals would be more likely to be treated on site, whereas uninsured neonates would be more likely to be transferred.

Patients and Methods

We used the Kids' Inpatient Database to study neonates with congenital anomalies who were born in US non-children's hospitals. We performed bivariate analysis using the χ² test and adjusted for covariates with multiple logistic regression.

Results

Uninsured patients were 2.57 (95% confidence interval, 1.83-3.62) times more likely to be transferred compared with patients with private insurance or Medicaid, after adjusting for patient and hospital characteristics. This trend increased over time between 1997 and 2006.

Conclusions

The current reimbursement structure in the United States incentivizes non-children's hospitals to retain insured patients with congenital anomalies and transfer uninsured patients with these same anomalies. This places a disproportionate financial burden on children's hospitals while paradoxically causing insured infants to be cared for at hospitals that may not be best equipped to provide complex care.     

Value of computed tomographic angiography in neck and extremity pediatric vascular trauma

Purpose

We sought to define the sensitivity and specificity of computed tomographic angiography (CTA) in pediatric vascular injuries.

Methods

All neck and extremity CTAs performed in pediatric patients at a level 1 trauma center were reviewed from 2001 to 2007.

Results

Overall, 78 patients were identified with an average age of 15.0 ± 4.0 (0-18 years). Males outnumbered females 3.6:1. CTA was performed for 41 penetrating and 37 blunt traumas. Most penetrating injuries were due to missile wounds (71%) or stab wounds (17%). Eleven major vascular injuries resulted from penetrating trauma. For penetrating trauma, CTA was 100% sensitive and 93% specific. CTA for penetrating trauma had a positive predictive value (PPV) of 85% and negative predictive value (NPV) of 100%. Most blunt injuries were due to motor vehicle accidents (57%), followed by pedestrian hit by car (27%). Eight major vascular injuries resulted from blunt trauma. For blunt trauma, CTA was 88% sensitive and 100% specific. CTA for blunt trauma had a PPV of 100% and an NPV of 97%. The accuracy for penetrating and blunt trauma was 95% and 97%, respectively.

Conclusions

CTA is highly sensitive, specific, and accurate for pediatric neck and extremity vascular trauma.     

Does age matter? The relationship between age and mortality in penetrating trauma

Purpose

Trauma is a significant cause of mortality among elderly patients, with blunt mechanisms accounting for the majority of deaths in this population. Penetrating trauma promises to evolve as an increasingly important aetiology of mortality in the elderly; particularly as the age composition of the overall population continues to shift. Unfortunately, very little data regarding outcomes following penetrating trauma in the elderly exists. The purpose of this study was to define the relationship between age and mortality following penetrating injuries and determine if differences between outcomes of elderly patients sustaining penetrating and blunt trauma exist.

Methods

After IRB approval, we conducted a retrospective trauma registry review at an urban Level 1 trauma centre between January 1, 1998 and December 31, 2005. Demographic, injury, and mortality data for all patients were recorded. The relationship between age and mortality for both blunt and penetrating injuries was examined by comparison of age-specific mortality and relative risk of mortality for both mechanisms at 10 year age intervals. Additionally, the relative risk and 95% confidence interval for mortality in each age group were compared.

Results

There were 26,333 blunt trauma admissions and 8843 penetrating trauma admissions during the 8-year study period. The mortality following both blunt and penetrating trauma remained stable until the age of 55 and increased steadily thereafter. When differences in mortality following blunt and penetrating mechanisms were examined, the overall mortality of penetrating trauma was found to be 2.63 times that of blunt (11.0% vs. 4.2%, RR 2.63; 95% CI: 2.42, 2.85, p < 0.0001). After adjustment for age and other confounding factors, the relative risk of mortality due to penetrating mechanisms was 1.65 (95% CI: 0.88, 2.89, p = 0.10) that of blunt mechanism counterparts. Although statistically higher in penetrating trauma, the relative risk of mortality between penetrating and blunt trauma decreased with increasing age.

Conclusion

The mortality rate with respect to penetrating trauma remains relatively constant until the age of 55, increasing thereafter. When compared to blunt trauma, the relationship between age and mortality in penetrating trauma is similar except that the relative mortality in penetrating trauma is significantly higher for each age group.     

Posttraumatic small bowel obstruction in children

Background

The diagnosis of intestinal injuries in children after blunt abdominal trauma can be difficult and delayed. Most children who suffer blunt abdominal trauma are managed nonoperatively, making the diagnosis of intestinal injuries more difficult. We sought to gain information about children who develop intestinal obstruction after blunt abdominal trauma by reviewing our experience.

Methods

Review of records from a pediatric tertiary care center over an 11.5-year period revealed 5 patients who developed small bowel obstruction after blunt trauma to the abdomen. The details of these patients were studied.

Results

All patients were previously managed nonoperatively for blunt abdominal trauma. Intestinal obstruction developed 2 weeks to 1 year (median, 21 days) after the trauma. Abdominal x-ray, computerized tomography scan, or barium meal studies were used to establish the diagnosis. The pathology was either a stricture, an old perforation, or adhesions causing the intestinal obstruction. Laparotomy with resection and anastomosis was curative.

Conclusions

Posttraumatic small bowel obstruction is a clinical entity that needs to be watched for in all patients managed nonoperatively for blunt abdominal trauma.     

Financial triage in transfer of trauma patients: a myth or a reality?

Background

It has been alleged that smaller hospitals transfer out uninsured trauma patients (wallet biopsy), putting the financial burden on major trauma centers.

Methods

We undertook a retrospective analysis of the National Trauma Data Bank to compare patients who received care at major trauma centers after being transferred from another hospital (transfer group, n = 72,900) with patients who received definitive care at a smaller hospital (nontransfer group, n = 6,826).

Results

Transfer patients were more likely to be uninsured (18% vs 14%; P < .001), but were more severely injured (Injury Severity Score, 11 ± 10 vs 7 ± 7; P < .001), or had multiple injuries. After adjustment for these differences, uninsured patients were no more likely to be transferred than insured ones (odds ratio, .95; 95% confidence interval, .88-1.04; P = .3).

Conclusions

There was no relationship between lack of insurance and likelihood of transfer to a major trauma center.     

Pediatric blunt and penetrating trauma deaths in Ontario: a population-based study

Purpose

The purpose of the study was to describe the mechanisms of injury and causes of death in children dying in a modern, integrated trauma system.

Method

Records of all children (<16 years of age) who died in Ontario from 2001 through 2003 after blunt or penetrating trauma were obtained from the Chief Coroner. Demographics and the nature and causes of injury and the causes of death were recorded. Estimates of the mortality rate were determined using census data.

Results

There were 234 injury deaths (222 blunt, 12 penetrating) over the 3 years. Thirty (13%) resulted from intentional injury. The median age was 10 (range, 0-15.9) years; 62% were male. Sixty-eight percent resulted from incidents involving motor vehicles (passenger, pedestrian, or cyclist). Most (74%) died at the scene; only 5% survived for more than 24 hours. Devastating craniocervical injury (Abbreviated Injury Scale 5 or 6) was present in 84% and was the only life-threatening injury in 40%. The annual mortality rate averaged 3.2 per 100,000 children.

Conclusions

In a modern, integrated trauma system, most pediatric injury deaths occur at the scene from severe head injuries. In this population, strategies to reduce the death rate from pediatric trauma must focus on primary and secondary injury prevention.     

Risk factors for blunt thoracic aortic injury in children

Background/Purpose

Because blunt thoracic aortic injury is rare in children, a high index of suspicion is needed to identify this injury. The purpose of this study was to use a large national trauma database to define the risk factors for blunt thoracic aortic injury in children.

Methods

Using the National Trauma Database, the authors compared patient demographics, mechanism of injury, and associated injuries between children sustaining blunt trauma with and without a thoracic aortic injury. Factors independently associated with this injury were identified using multivariate methods.

Results

Among 26,940 children with a blunt mechanism of injury, 34 (0.1%) children sustained a thoracic aortic injury, 14 (41%) of whom died. Thoracic aortic injuries were independently associated with age, injury sustained as an occupant in a motor vehicle crash, and severe injuries (Abbreviated Injury Scale value of ≥3) involving the head, thorax (other than aorta), abdomen, and lower extremities.

Conclusions

Older children involved in a motor vehicle crash with severe head, torso, and lower extremity injuries are a group at high risk for injury to the thoracic aorta. These easily identifiable risk factors may facilitate more rapid identification of this rare and potentially fatal injury.     

Abdominal wall injuries occurring after blunt trauma: incidence and grading system

Background

Traumatic abdominal wall injuries (AWIs) are being increasingly recognized after blunt force injury.

Methods

All available abdominal/pelvic computed axial tomography (CAT) scans of blunt trauma patients evaluated at our level I trauma center from January 2005 to August 2006 were reviewed for the presence of AWI. AWI was graded using a severity-based numeric system. AWI grade was then compared with variables from a prospectively maintained trauma registry.

Results

Of 1549 reviewed CAT scans, 9% showed AWI (grade I = 53%, grade II = 28%, grade III = 9%, grade IV = 8%, and grade V = 2%). There was no association between AWI and seatbelt use, Injury Severity Score, weight, or need for abdominal surgery.

Conclusions

AWI occurs in 9% of blunt trauma patients undergoing abdominal/pelvic CAT scans. The incidence of herniation on CAT at presentation after blunt trauma is .2%, and the incidence of patients at risk of future hernia formation is 1.5%. AWI can be effectively cataloged using a straightforward numeric grading system.     

Long-term outcome of nonoperative pediatric splenic injury management

Background

Nonoperative management (NOM) of blunt splenic trauma is the standard of care in hemodynamically stable children. The long-term risk of this strategy remains unknown. The object of this study was to investigate the incidence of long-term complications after NOM of pediatric splenic injury.

Methods

All children who underwent NOM for blunt splenic trauma over an 11-year period were identified. Patients were interviewed for any ailments that could be related to their splenic injury, and hospital data were analyzed.

Results

A total of 266 patients were identified, and 228 patients (86%) were interviewed. Mean follow-up time was 5 ± 3 years. One patient had a delayed complication, a splenic pseudocyst. Pain more than 4 weeks after injury was unusual. Time until return to full activity varied broadly.

Conclusion

The incidence of long-term complications after NOM of pediatric splenic injury was 1 (0.44%) in 228 patients. Nonoperative management of pediatric blunt splenic trauma in children is associated with a minimal risk of long-term complications.     

Presence of pneumomediastinum after blunt trauma in children: what does it really mean?

Background

Pneumomediastinum after blunt thoracic trauma is often considered a marker of serious aerodigestive injury that leads to invasive testing. However, the efficacy of such testing in otherwise stable children remains unknown. We hypothesize that pneumomediastinum after blunt trauma in clinically stable children is rarely associated with significant underlying injury.

Methods

We reviewed all patients in our pediatric trauma database (1997-2007) for pneumomediastinum after blunt injury. Patients were then subdivided into 2 groups: group I, isolated thoracic and group II, thoracic and additional injuries. Procedures and imaging were recorded, and outcomes were assessed.

Results

Thirty-two children with blunt thoracic trauma were included as follows: group I (n = 14) and group II (n = 18). In all patients, there were 28 diagnostic procedures performed resulting in only 1 positive test—a bronchial tear found on bronchoscopy in association with obvious respiratory distress. Group I was more than twice as likely to undergo invasive procedures as group II (P < .0001), resulting in significantly greater costs (?$13683 ± 2520 vs $5378 ± 1000; P < .002). Patients in group I also received more diagnostic imaging to assess pneumomediastinum (1.89 vs 1.08 studies/patient per day; P < .05). More than 28% of all patients were completely asymptomatic and had pneumomediastinum as their only marker of injury. Strikingly, these patients received more than 46% of the procedures.

Conclusions

Children with pneumomediastinum from blunt trauma often receive invasive and expensive testing with low yield, especially those with isolated thoracic trauma.     

Is the prevalence of deliberate penetrating trauma increasing in London? Experiences of an urban pre-hospital trauma service

Background

Recent media interest in stabbings and shootings has lead to the general assumption that injury and death secondary to deliberate penetrating trauma are rising. The aim of this study was to establish the prevalence of deliberate penetrating trauma within a London-based physician-led pre-hospital trauma service, and evaluate whether the perceived increase reported by the media translates into a real increase in penetrating trauma caseload.

Method

A retrospective review of a physician-led pre-hospital care trauma database was conducted to identify all patients who sustained stabbing or shooting injuries over a 16-year period. Patients who died in the pre-hospital phase and paediatric patients were included. Other local and national datasets were examined to determine whether similar trends were observed.

Results

1564 penetrating trauma victims were identified, including 92 children. 1358 patients (86.8%) sustained stab wounds; 206 patients were shot (13.2%). Penetrating injury accounted for 9.9% of the overall trauma caseload during the study period. The annual increase in patients sustaining stabbing injuries was 23.2%. Gun shot wounds increased by 11.0% per year.

Conclusion

The study demonstrates a significant annual rise in the number of cases of deliberate penetrating trauma managed by a UK physician-led pre-hospital trauma service.     

Traumatic pseudoaneurysms of the liver and spleen in children: is routine screening warranted?

Background

Although blunt injury to the spleen and liver can lead to pseudoaneurysm formation, current surgical guidelines do not recommend follow-up imaging. Controversy exists regarding the clinical implications of these traumatic pseudoaneurysms as well as their management.

Methods

Retrospective review of children treated nonoperatively for isolated blunt liver and spleen trauma between 1991 and 2008 was undertaken. Patient demographics, grade of injury, and follow-up Doppler ultrasound results were obtained.

Results

Three hundred sixty-two children were identified. One hundred eighty-six of them had splenic injuries, and 10 (5.4%) developed pseudoaneurysms. They were associated with grade III (3/39 [8%]) and grade IV (7/41 [17%]) injuries. In 7 patients, the pseudoaneurysm thrombosed spontaneously. Angiographic embolization was required in 2 children, and one underwent emergency splenectomy for delayed hemorrhage. Of the 176 patients who had liver injuries, 3 (1.7%) developed pseudoaneurysms. All 3 were associated with grade IV injuries (3/11 [27%]). One child underwent early embolization, while 2 developed delayed hemorrhage requiring emergent treatment.

Conclusions

Pseudoaneurysm development after blunt abdominal trauma is associated with high-grade splenic and liver injuries. Routine screening of this group of patients before discharge from hospital may be warranted because of the potential risk of life-threatening hemorrhage.     

Occult pneumothorax in the blunt trauma patient: Tube thoracostomy or observation?

Background

The term occult pneumothorax (OP) describes a pneumothorax that is not suspected on the basis of either clinical examination or initial chest radiography, but is subsequently detected on computed tomography (CT) scan. The optimal management of OP in the blunt trauma setting remains controversial. Some physicians favour placement of a thoracostomy tube for patients with OP, particularly those undergoing positive pressure ventilation (PPV), while others favour close observation without chest drainage. This study was conducted both to determine the incidence of OP and to describe its current treatment status in the blunt trauma population at a Canadian tertiary trauma centre. Of interest were the rates of tube thoracostomy vs. observation without chest drainage and their respective outcomes.

Methods

A retrospective review was conducted of the Nova Scotia Trauma Registry. The data on all consecutive blunt trauma patients between October 1994 and March 2003 was reviewed. Outcome measures evaluated include length of stay, discharge status—dead vs. alive, intervention and time to intervention (tube thoracostomy and its relation to institution of PPV). Direct comparison was made between the OP with tube thoracostomy group and OP without tube thoracostomy group (observation or control group). They were compared in terms of their baseline characteristics and outcome measures.

Results

In 1881 consecutive blunt trauma patients over a 102-month period there were 307 pneumothoraces of which 68 were occult. Thirty five patients with OP underwent tube thoracostomy, 33 did not. Twenty nine (82.8%) with tube thoracostomy received positive pressure ventilation (PPV), as did 16 (48.4%) in the observation group. Mean injury severity score (ISS) for tube thoracostomy and observation groups were similar (25.80 and 22.39, p = 0.101) whereas length of stay (LOS) was different (17.4 and 10.0 days, p = 0.026). Mortality was similar (11.4% and 9.1%). There were no tension pneumothoraces.

Conclusion

The natural history of OP in blunt trauma patients at our institution appears to be one of uneventful resolution irrespective of ISS, need for PPV, or placement of tube thoracostomy. This study suggests an interesting hypothesis that observation of the blunt trauma patient with OP, without tube thoracostomy, may be safe and contribute to a shorter hospital stay. These are observations that would benefit from further study in a large, prospective randomised controlled trial.     

Recombinant factor VIIa as an adjunct in nonoperative management of solid organ injuries in children

Background

Ongoing bleeding after blunt solid organ injury in children may require invasive therapy in the form of either angiographic or operative control. We report our experience in the use of a procoagulant, recombinant activated factor VII (rFVIIa), for controlling persistent bleeding in blunt abdominal trauma in children.

Methods

After institutional review board approval, the records of 8 children with blunt abdominal trauma, persistent bleeding, and managed nonoperatively with rFVIIa were reviewed.

Results

All 8 patients presented to our institution after sustaining blunt abdominal trauma and solid organ injury. All children had evidence of persistent bleeding with a drop in hematocrit and elevation in heart rate. Patients received a single dose of rFVIIa at 75 to 90 μg/kg (1 patient had 24 μg/kg) and had successful control of their bleeding without any further therapeutic intervention. Only 3 patients required a blood transfusion after rFVIIa administration—2 who had subarachnoid hemorrhages and the third during pelvic fixation. There were no cases of thromboembolic events after treatment with rFVIIa.

Conclusions

Recombinant factor VIIa is a useful adjunctive therapy in pediatric patients with evidence of ongoing hemorrhage from blunt abdominal injury and may reduce the need for invasive therapeutic procedures and transfusions.     

Airway management for victims of penetrating trauma: analysis of 50,000 cases

Background

Current recommendations for victims of penetrating trauma include prompt transportation to a trauma center. It remains unclear whether field intubation allows for improvements in mortality rate.

Methods

A retrospective review of the National Trauma Data Bank of adult victims of penetrating trauma was performed. Standard demographic data, method, and location of airway management were examined. Mortality rate was used as the primary outcome measure.

Results

There were 56,094 victims of penetrating trauma identified. A total of 1,925 patients required a prehospital airway. The mortality rate for patients who underwent airway management at the scene was 69.2%, compared with a rate of 35.9% for patients in whom airway management was deferred. The mortality rate for patients undergoing surgical airway management at the scene was only 23.9%.

Conclusions

Victims of penetrating trauma who require any airway management have a high mortality rate. The cause of this difference awaits further prospective investigation.     

Oral candidiasis in patients receiving radiation therapy for head and neck cancer

Objective

To investigate oral candidiasis in patients with head and neck cancer before, during, and after radiation therapy, and to explore its association with clinical oropharyngeal symptoms.

Study Design

A cohort study.

Setting

University hospital.

Subjects and Methods

Subjects who received radiation therapy (RT) for the treatment of head and neck cancer were divided into two groups: an oral cavity irradiated group (OIRR group, n = 29) and an oral cavity nonirradiated group (ONIRR group, n = 17). A control group consisted of 18 healthy subjects. Patients were examined for signs of oral candidiasis before, during, immediately after, and one month after RT. Mouth and throat soreness (MTS), dysphagia, and xerostomia were evaluated by self-reported questionnaires, and associations between oral candidiasis and these symptoms were analyzed.

Results

The incidence of oral candidiasis during RT was significantly higher in the OIRR group (55.2%) than in the ONIRR group (11.8%). Similarly, the occurrence of xerostomia during RT was significantly higher in the OIRR group (86.2%) than in the ONIRR group (52.9%). In the OIRR group, the mean MTS score at the 20th fraction of RT was significantly higher in patients with candidiasis (mean ± SD, 5.8 ± 2.1) than in those with RT-induced mucositis without candidiasis (3.7 ± 2.0). In the OIRR group, 65.2 percent of patients who experienced dysphagia developed oral candidiasis, compared with only 10 percent in the ONIRR group.

Conclusion

Oral candidiasis concurrent with oral mucositis due to RT may increase oropharyngeal discomfort during RT.     

Pediatric pancreatic trauma: predictors of nonoperative management failure and associated outcomes

Background

Nonoperative management (NOM) is an accepted treatment of pediatric solid organ injuries and is typically successful. Blunt pancreatic trauma tends to require operative intervention more frequently. We sought to identify predictors of failure of NOM and compare the outcome of operative management against NOM.

Methods

A retrospective analysis was performed from January 1993 to December 2002 of all children with blunt pancreatic injuries from the trauma registries of 7 designated level 1 pediatric trauma centers. Failure of NOM was defined as the need for intraabdominal operative intervention. Injuries were graded I to V, and ductal injury was defined as grades III to V. Parameters included mechanism of injury, injury severity score (ISS), organ grade, Glasgow Coma Scale score, and outcome. Data were analyzed by Fisher exact test and Mann-Whitney U test, with mean values ± SD and significance of P < .05.

Results

Pancreatic injuries were present in 173 (9.2%) of 1823 patients. Of these, 43 (26.0% [43/173]) required an operation. Valid morbidity data was obtained in 118 of 173 patients. ISS was significantly higher in all patients treated operatively. Patients with an injury of grade III to V failed NOM more frequently than all patients with pancreatic injury (P =.0169). Length of stay was longer, and the incidence of pseudocysts, drainage procedures, and pancreatitis was higher in NOM patients, although not significant.

Conclusions

Patients with pancreatic injuries had a NOM failure rate of 26.0%. ISS and injury grades III to V were predictors of NOM failure. Patients with pancreatic ductal injury require more aggressive management.